Combination of the National Early Warning Score (NEWS) and inflammatory biomarkers for early risk stratification in emergency department patients: results of a multinational, observational study

Abstract

ObjectivesThe National Early Warning Score (NEWS) helps to estimate mortality risk in emergency department (ED) patients. This study aimed to investigate whether the prognostic value of the NEWS at ED admission could be further improved by adding inflammatory blood markers (ie, white cell count (WCC), procalcitonin (PCT) and midregional-proadrenomedullin (MR-proADM).DesignSecondary analysis of a multinational, observational study (TRIAGE study, March 2013–October 2014).SettingThree tertiary care centres in France, Switzerland and the USA.ParticipantsA total of 1303 adult medical patients with complete NEWS data seeking ED care were included in the final analysis. NEWS was calculated retrospectively based on admission data.Main outcome measuresThe primary outcome was all-cause 30-day mortality. Secondary outcome was intensive care unit (ICU) admission. We used multivariate regression analyses to investigate associations of NEWS and blood markers with outcomes and area under the receiver operating curve (AUC) as a measure of discrimination.ResultsOf the 1303 included patients, 54 (4.1%) died within 30 days. The NEWS alone showed fair prognostic accuracy for all-cause 30-day mortality (AUC 0.73), with a multivariate adjusted OR of 1.26 (95% CI 1.13 to 1.40, p<0.001). The AUCs for the prediction of mortality using the inflammatory markers WCC, PCT and MR-proADM were 0.64, 0.71 and 0.78, respectively. Combining NEWS with all three blood markers or only with MR-proADM clearly improved discrimination with an AUC of 0.82 (p=0.002). Combining the three inflammatory markers with NEWS improved prediction of ICU admission (AUC 0.70vs0.65 when using NEWS alone, p=0.006).ConclusionNEWS is helpful in risk stratification of ED patients and can be further improved by the addition of inflammatory blood markers. Future studies should investigate whether risk stratification by NEWS in addition to biomarkers improve site-of-care decision in this patient population.Trial registration number NCT01768494; Post-results.

The Importance of Respiratory Rate Monitoring: From Healthcare to Sport and Exercise

“…This is important for timely critical care assistance because f R may increase several hours before the occurrence of an adverse event [4,118,119], and such f R changes should be promptly identified. However, despite the clinical relevance of f R , this vital sign is often under-recorded [29,37,120,121] or not measured accurately [38,59,60,[122][123][124]. This may impair the efficacy of early warning scores [118,120,121], which also suffer from other methodological issues [109,110].…”

Development and validation of a scoring system for mortality prediction and application of standardized W statistics to assess the performance of emergency departments

“…Although scoring systems such as the Acute Physiology and Chronic Health Evaluation (APACHE) score or Simplified Acute Physiology Score were developed to predict in-hospital mortality, the application of these systems in the general ED population is limited because they rely on laboratory values that are often not measured in ED patients with relatively mild complaints and are not included in national databases [ 24 – 27 ]. A recent multinational study found that the National Early Warning Score (NEWS) can predict mortality among adult medical patients in the ED with an AUROC of 0.73, and the combination of the NEWS and laboratory biomarkers yielded an AUROC of 0.82 [ 16 ]. Some investigators developed machine-learning models for the prediction of death or admission to intensive care units among ED patients and reported the AUROCs of their models to be between 0.84 and 0.87 [ 15 , 28 ].…”

“…In the field of trauma care, methods of comparing performance between institutions or trauma systems have been developed and widely used, including the W statistic and standardized W (Ws) based on the Trauma and Injury Severity Score (TRISS) [ 6 , 7 , 10 – 14 ]. Although several scoring systems and machine learning-based approaches have been suggested to grade the severity of illness in ED patients, methods of comparing the severity-adjusted mortality of general ED patients between different systems have yet to be developed [ 15 , 16 ].…”

Retrospective study on the possible existence of a treatment paradox in sepsis scores in the emergency department

“… 18 19 One retrospective analysis aimed to improve the National Early Warning Score by adding inflammatory blood marker addresses that their results could have been influenced by a treatment paradox, but this study was not specifically performed in patients at risk for sepsis. 20 Future research on validating existing scores and developing new prediction models in sepsis should address these methodological issues by using other data sources like additional testing, follow-up, response to treatment or expert panels estimating sepsis risk and combining the imperfect information through latent class models and/or measurement error models. A recent framework by van Geloven et al 21 is a useful starting point to evaluate the various types of predictions that can be made that explicitly incorporate the use of treatments.…”